An Interview With Stephane Manzo-Silberman, MD, MPH

You’ve carved out a unique niche in interventional cardiology, focusing on coronary heart disease in women and cardiogenic shock. What pivotal moments cemented this as your career path, and how have your research and clinical priorities evolved throughout the course of your career?

My interest in these two topics—coronary artery disease in women and cardiogenic shock—was driven by a need to understand. Indeed, to varying degrees, these are two areas in which there are differences in prognosis and a gap in knowledge to explore. I was fortunate early in my career to work with teams specialized in the management of cardiac arrest and to collaborate with intensivists. We implanted the first Impellas (Abiomed, Inc.) in France in 2006!

Regarding coronary artery disease in women, my interest stems from the clinical observation of their less favorable management and the diversity of physiopathologic mechanisms. This interest was further reinforced by collaborations with female interventional colleagues whom I had the chance to meet, notably at the Society for Cardiovascular Angiography and Interventions (SCAI) Women in Innovations conference in 2010 in Chicago, Illinois.

From leading the WAMIF trial as Principal Investigator to a recent “call-to-action” piece in European Heart Journal Open,¹ you have called much attention to acute myocardial infarction (AMI) in young women. What do we need to see happen within the next decade to address the rise of AMI among young women?

The objectives of WAMIF were to better define the profile of these young women who have had a myocardial infarction in order to develop more effective screening and treatment strategies. This is what we wanted to emphasize in the call-to-action article.

We can optimize all levels of intervention to improve the prognosis of these women once the myocardial infarction has occurred, but above all, we need to halt this upward trend in incidence. This requires better public awareness of risk factors and symptoms, as well as better training of all health care professionals regarding the specificities of women. We are also observing a global movement toward stricter management of risk factors such as hypertension and dyslipidemia, while intervention thresholds and maximum targets continue to decrease. Perhaps we should consider thresholds based on sex or body surface area?

As Chair of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Patient Advocacy Committee, what initiatives are you driving during your term, and how do you see them benefiting both patients and physicians?

Within the EAPCI Patient Advocacy Committee, we aim to invest more at the individual level to improve the prognosis of patients with coronary, myocardial, and valvular diseases. It seems crucial that patients be more involved in the therapeutic approach and research advances. Well-being and quality of life should also be among the main evaluation criteria.

We have decided to invest in four projects:

• A single consensus document on patient information for coronary interventions to standardize patient information
• Evaluation of the experience, perception, and feedback of patients after admission for acute coronary syndrome. What information is actually collected and stored?
• Efforts with specific actions for women, particularly regarding participation in clinical trials. What are the barriers, and how can they be overcome?
• A project dedicated to patients with structural heart disease, particularly aortic stenosis. What are the differences in perception and symptoms between men and women?

What is one piece of technology or trial data that would revolutionize your approach to cardiogenic shock?

The key to management is the ability to accurately and easily diagnose shock, define its phenotype, and anticipate its prognosis. Thanks to the progress made and the classifications developed, particularly via SCAI, major advances have been made. The revolution could come from the development of adapted circulatory support devices to detect mechanical failure without complications.

You’ve been a leading advocate for radiation safety in the cath lab, particularly as it concerns pregnancy, as reflected in your 2023 societal statement.² How have these efforts changed practice so far?

Change is still a long time coming. Our document aimed to clarify existing data regarding the risks of radiation exposure during pregnancy and overcome this barrier that prevented young women from choosing this specialty or department heads from recruiting young women. Risks exist, and they must be understood, but raising awareness concerns all operators: women and men alike, who are equally concerned about the risks to fertility.

What other barriers, beyond radiation misconceptions, still deter women from entering the field? What message would you give to a woman considering this field?

The radiation barrier has not yet been completely overcome!

In terms of other barriers, this specialty emphasizes apprenticeship training; co-opting (ie, mentorship) thus plays a major role, and it is not in favor of women. With the continued underrepresentation of women in interventional teams, particularly in supervisory and management positions, female trainees have less opportunities for this support.

These female colleagues may struggle with certain difficulties of the practice (eg, access to a fellowship position, overall support to pursue interventional cardiology, finding good counsel or a role model) or even choose not to continue despite their interest in the discipline due to certain not-so-rare situations of harassment from their elders.

However, considerable progress is underway under the impetus of formidable mentors in our discipline, including Dr. Alaide Chieffo and Prof. Martine Gilard within the European Society of Cardiology/EAPCI, as well as Dr. Roxana Mehran with the American College of Cardiology. These societies, along with initiatives such as Women As One, provide incredible support in terms of career and scientific development.

Progress in this area is more favorable now than even a few years ago. I recommend without hesitation that female interventional cardiologists continue in this specialty—one that has undergone significant development and innovation and is constantly evolving. The discipline needs women to continue its evolution, in the service of patients.

What do you find most rewarding, and most challenging, about the current phase of your career?

At this stage, the most rewarding aspects are the knowledge acquired, the overall understanding of certain mechanisms, and the perception of knowledge gaps. With a more global vision, we can more clearly see the avenues of research and how to approach them. We also gain a certain legitimacy in terms of recognition from patients, who no longer ask, “When will the doctor arrive?” after you’ve performed an angioplasty on them! This phase of my career also gives me the opportunity to supervise younger patients and pass on what I've been taught.

The hardest part is realizing that there are still many, truly many, areas to explore and improve. Curiosity is never satisfied but rather fueled along the way.

1. Manzo-Silberman S, Hawranek M, Banerjee S, et al. Call to action for acute myocardial infarction in women: international multi-disciplinary practical roadmap. Eur Heart J Open. 2024;4:oeae087. doi: 10.1093/ehjopen/oeae087

2. Manzo-Silberman S, Velázquez M, Burgess S, et al. Radiation protection for healthcare professionals working in catheterisation laboratories during pregnancy: a statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the ESC Regulatory Affairs Committee and Women as One. EuroIntervention. 2023;19:53-62. doi: 10.4244/EIJ-D-22-00407